Selective recovery of boron, cobalt, gallium and germanium from seawater solar saltworks brines using N-methylglucamine sorbents: Column operation performance

The European Union (EU) identified a list of Critical Raw Materials (CRMs) crucial for its economy, aiming to find alternative sources. Seawater is a promising option as it contains almost all elements, although most at low concentrations. However, to the present, the CRMs' recovery from seawater is technically and economically unfeasible. Other alternatives to implement sea mining might be preferred, such as reverse osmosis brines or saltworks bitterns (after sodium chloride crystallisation). The CRMs' extraction in a selective way can be achieved using highly selective recovery processes, such as chelating sorbents. This study focuses on extracting Trace Elements (TEs) from solar saltworks brines, including boron, cobalt, gallium and germanium, using commercial N-methylglucamine sorbents (S108, CRB03, CRB05). The application of these sorbents has shown potential for boron recovery, but their selectivity for cobalt, gallium, and germanium requires further investigation. This research aims to assess these sorbents' kinetics and column mode performance for TEs recovery from synthetic bitterns. Boron and germanium were rapidly sorbed, reaching equilibrium (>90 %) within 1 h, except for S108, which took 2 h. In column mode, 20-25 pore volumes of bittern were treated to remove boron and germanium, but competition from other elements reduced treatment capacity. An acidic elution (1 M hydrochloric acid) allowed to elute them (>90 %), reaching concentration factors for germanium and boron of 35 and 11, respectively, while cobalt and gallium had less affinity for the sorbents. In addition, the experiments performed were fitted by a mass transfer model to determine the equilibrium constants and selectivities. Therefore, bittern mining has been proven as a secondary/alternative source to obtain CRMs, which can lead the EU to a position in which its dependence on other countries to obtain these raw materials would be decreased.

Proteasome-dependent degradation of histone H1 subtypes is mediated by its C-terminal domain

Histone H1 is involved in chromatin compaction and dynamics. In human cells, the H1 complement is formed by different amounts of somatic H1 subtypes, H1.0-H1.5 and H1X. The amount of each variant depends on the cell type, the cell cycle phase, and the time of development and can be altered in disease. However, the mechanisms regulating H1 protein levels have not been described. We have analyzed the contribution of the proteasome to the degradation of H1 subtypes in human cells using two different inhibitors: MG132 and bortezomib. H1 subtypes accumulate upon treatment with both drugs, indicating that the proteasome is involved in the regulation of H1 protein levels. Proteasome inhibition caused a global increase in cytoplasmatic H1, with slight changes in the composition of H1 bound to chromatin and chromatin accessibility and no alterations in the nucleosome repeat length. The analysis of the proteasome degradation pathway showed that H1 degradation is ubiquitin-independent. The whole protein and its C-terminal domain can be degraded directly by the 20S proteasome in vitro. Partial depletion of PA28γ revealed that this regulatory subunit contributes to H1 degradation within the cell. Our study shows that histone H1 protein levels are under tight regulation to prevent its accumulation in the nucleus. We revealed a new regulatory mechanism for histone H1 degradation, where the C-terminal disordered domain is responsible for its targeting and degradation by the 20S proteasome, a process enhanced by the regulatory subunit PA28γ.

Imaging leachate runoff from a landfill using magnetotellurics: The Garraf karst case

Electrical and active source electromagnetic geophysical methods have been traditionally employed to approach and tackle environmental problems, such as those caused by landfills. However, since these problems are more consequential and cover broader areas, it is necessary to use deeper penetration methods, such as magnetotellurics. In the Garraf Massif (Catalan Coastal Ranges, NE Spain), an urban waste disposal landfill had been in operation from 1974 to 2006, during which >26 million metric tons of garbage had been deposited. This landfill overlies karstic terrain, thus principally impacting groundwater circulation. Previous electrical resistivity tomography profiles had partially imaged the infill but were not able to penetrate below the base of the original landfill. During 2019 and 2020 we performed a magnetotelluric study over the landfill and its surrounding with the goals of characterizing the electrical resistivity of the infill and below it. The 2D and 3D resistivity models confirmed the highly conductive nature of the leachate and allowed us to identify its presence below the landfill base, which we quantified with maximum thicknesses of 90 m. This proved that landfill leachate had filtered through the original impermeable layer, enhanced by the karstic drainage structure.

Development and validation of a clinical score for early diagnosis of constipation in critically ill children

Constipation affects almost 50% of critically ill pediatric patients and is related to their morbidity and mortality. However, little attention is paid to it and it is diagnosed late and when there are already complications. The objective of this study is to develop and validate a score to identify critically ill children with high risk of constipation 48 h after admission. A single center two phase-study was carried out; the first one (retrospective observational study) to develop the score and the second one to validate it in another prospective observational study. Children between 15 days of life and 18 years old admitted to the PICU for more than 3 days were included. Demographic and clinical data during the first 48 h after PICU admission were collected. Univariate and multivariate analysis and ROC curves were used to develop and validate the score. Data from 145 patients (62.8% boys) with a mean age of 34.9 ± 7.3 months were used to develop the score. Independent factors identified to develop the score were: weight > 7 kg, admission to PICU after surgery, need of vasoconstrictors, doses of fentanyl ≥ 2 mcg/kg/h, and initiation of enteral nutrition later than 48 h after admission. Two cut-off values were identified to set low constipation risk (< 5.7 points) and high constipation risk (> 6.2 points). This score was validated in 124 patients showing a sensibility of 63.2%, specificity of 95.5% and a positive/negative predictive values (P/NPV) of 100% and 82.1% respectively to identify constipated patients. This is the first score to identify high constipation risk in critically ill children. This score is easy to apply, and internal validation has shown a PPV of 100%.

DISGUISED INGUINAL HERNIA

Introduction

Liposarcomas are malignant neoplasms that originate in fatty mesenchymal tissue and are the most common histological subtype of soft tissue sarcomas. They account for 1% of solid tumors in adults and are located mainly in the extremities, with the retroperitoneum being the second most frequent location. Given the rarity and aggressiveness of these tumors, it is advisable to establish a multidisciplinary approach towards them in order to improve the prognosis of patients.

Clinical case

Patient who was operated upon on a scheduled and outpatient basis for a left inguinal hernia. During surgery, a preperitoneal tumor was identified that was removed and revealed a high-grade dedifferentiated liposarcoma. In a second surgical act, a tumor mass of about 10 centimeters in length was found, lodged in the left pelvis and contacting sigma, which extended into the inguinal duct and scrotal pouch. Finally, compartment surgery and a left orchiectomy with end-to-end colo-sigmoid anastomosis were performed.

Discussion

Routine examination of the masses contained in the hernial sacs is recommended since, despite their infrequency (&lt;0.1%), cases of liposarcomas that have their origin in the inguinal canal have been described. Surgery for retroperitoneal sarcomas must be compartmental, which requires the inclusion of viscera close to the tumor in the resection. Complete surgical resection R0 is the only potentially curative treatment. Compartment surgery should be performed by expert surgeons in referral centers with multidisciplinary teams to improve the prognosis of these patients.

HEMORRHOIDS AGAIN?

Introduction

Anal cancer represents 4% of digestive tract tumors, although its incidence is increasing due to the growing number of patients with HPV infection, who are immunosuppressed or who practice anal sex. The most common histological type is carcinoma and the usual standard treatment is the combination of radiotherapy with chemotherapy. Survival at 5 years exceeds 50% even in patients with nodal disease.

Clinical case

We present the case of a 54-year-old man, with a history of anal intercourse, referred to General Surgery for hemorrhoids. During the examination in consultation, an ulcerated excrescent anal lesion was observed. A rectal swab was taken for sexually transmitted diseases and a biopsy of the lesion was HPV+, genotype 16. In the pathology study, anal squamous cell carcinoma was diagnosed. An extension study was performed, objectifying bilateral inguinal lymphadenopathies (N1a) and treatment with radiochemotherapy was started after a decision made by the multidisciplinary tumor committee.

Discussion

Anal squamous cell carcinoma is the most frequent histological variety of malignant tumors of the anus. The first-line treatment is radiotherapy (which must be to the inguinal region) associated with chemotherapy (5-FU and mitomycin C). A clinical follow-up should be carried out in all cases at 8–12 weeks and, in addition, an annual extension radiological study in locally advanced cases. Rescue surgery will be reserved for those patients with confirmed locoregional recurrence, with abdominoperineal amputation being the indicated technique in most cases.

Mining minerals and critical raw materials from bittern: Understanding metal ions fate in saltwork ponds

Seawater represents a potential resource for raw materials extraction. Although NaCl is the most representative mineral extracted other valuable compounds such as Mg, Li, Sr, Rb and B and elements at trace level (Cs, Co, In, Sc, Ga and Ge) are also contained in this "liquid mine". Most of them are considered as Critical Raw Materials by the European Union. Solar saltworks, providing concentration factors of up-to 20 to 40, offer a perfect platform for the development of minerals and metal recovery schemes taking benefit of the concentration and purification achieved along the evaporation saltwork ponds. However, the geochemistry of these elements in this environment has not been yet thoroughly evaluated. Their knowledge could enable the deployment of technologies capable to achieve the recovery of valuable minerals. The high ionic strengths expected (0.5-7 mol/kg) and the chemical complexity of the solutions imply that only numerical geochemical codes, as PHREEQC, and the use of Pitzer model to estimate the activity coefficients of the different species in solution can be adopted to provide valuable description of the systems. In the present work, for the first time, PHREEQC Pitzer code database was extended to include the target minor and trace elements using Trapani saltworks (Sicily, Italy) as a case study system. The model was able to predict: i) the purity in halite and the major impurities contained, mainly Ca, Mg and sulphate species; ii) the fate of minor components as B, Sr, Cs, Co, Ge and Ga along the evaporation ponds. The results obtained pose a fundamental step in critical raw materials mining from seawater brine, for process intensification and combination with desalination.

A multidimensional approach to the resilience in older adults despite COVID-19

Researchers have mainly focused on aging risk factors and COVID-19 consequences. However, older adults have proved their ability to overcome adversities along their life. Resilience is a protective variable that dampens the impact of stress. Based on MacLeod’s et al. (2016) approach, we aimed to analyze the relationship between older adults’ resilience and COVID-19 related-stressors as well as their physical, mental, and social characteristics. Eight hundred eighty-nine people aged 60 and over participated in this study. Older participants, women, having better perceived health and not losing a loved one because of the virus were associated with more resilience. Moreover, higher levels of gratitude, personal growth, life purpose and lower levels of depression were associated with greater scores in resilience. This study offers a change of perspective in which aging is perceived from a positive viewpoint by focusing on easily accessible resources that may help older adults to cope with adverse situations.

Modelling the Reduction in Cancer Incidence After Variations in the Prevalence of Tobacco Consumption in Colombia in the Period 2016-2050

Objective

To evaluate the potential impact of tobacco reduction on future cancer incidence in Colombia

Introduction

Colombia has implemented multiple actions that led to reducing smoking prevalence in recent years. However, the numbers of cancer cases and deaths associated with smoking exposure remain high highlighting the importance of maintaining efforts to reduce and keep smoking prevalence low.

Methods

We performed a theoretical modeling exercise, projecting expected changes in the incidence of four cancers between 2016 and 2050 under two simulated scenarios of smoking reduction.

Results

A cumulative decline of 10% in the prevalence of smoking, a percentage in line with current cigarette taxation policies, will decrease cancer incidence in 2050 by 3.2%, .5%, .2% and .2% of lung, liver, cervical and colorectal cancer incidence, respectively. Complete elimination of tobacco consumption will reduce these by 39.1%, 6.1%, 2.2% and 2.3% respectively, by 2050.

Conclusion

These results highlight the importance of continuity and reinforcement of current tobacco control programs, including increasing taxation, to further reduce the prevalence of tobacco smoking and reduce cancer cases and deaths in the coming decades.

Management of congenital and acquired airway pathologies in newborns by a cross-disciplinary committee at a third level hospital

INTRODUCTION

Neonatal airway examination through flexible/rigid bronchoscopy has proved to be useful in the presence of persistent stridor and extubation failure, as well as to assess complications following cardiac surgery. At our institution, these examinations are carried out by a pulmonologist, a neonatologist, an otorhinolaryngologist, and a pediatric surgeon from the pediatric airway committee, established in 2014.

OBJECTIVE

To analyze the airway examinations performed in neonates during their stay at the neonatology/neonatal intensive care unit since the airway committee was established.

MATERIAL AND METHODS

A retrospective study of the airway examinations conducted in neonates from 2015 to 2019 was carried out. Clinical and demographic data, number of examinations, indications, findings, and complications were collected. Results are presented as mean and standard deviation. Statistical significance was established at p < 0.05.

RESULTS

92 airway examinations were analyzed in 51 patients (54.9% of whom were female). 51% of the patients were premature. Extubation failure and persistent respiratory symptoms following successful extubation were the most frequent indications for airway examination (35.3%). Stratification by gestational age or weight at birth was not associated with an increased risk of pathological findings at examination (p > 0.05). The most frequent finding was vocal cord paralysis (n = 14; 27.5%). In 10 patients (19.6%), no pathological findings were observed.

CONCLUSION

Airway examination is useful in patients with stridor to identify vocal cord paralysis following extubation failure. It also allows congenital airway pathologies to be diagnosed and treated. The number of examinations with no pathological findings was similar to that reported in international series.

Integration of membrane distillation as volume reduction technology for in-land desalination brines management: Pre-treatments and scaling limitations

Management of in-land reverse osmosis (RO) desalination brines generated from surface brackish waters is a current challenge. Among the different near-Zero and Zero Liquid Discharge (ZLD) alternatives, Membrane Distillation (MD), in which the transport of water is thermally driven, appears as an attractive technology if a residual heat source is available. The aim of this study was to identify the limits of Direct Contact MD (DCMD) pre-treatments such as acidification and aeration, or the combination of both to quantify the scaling reduction potential when treating a RO brine from surface brackish water. Experimental data were used to evaluate the effectiveness of DCMD to achieve the highest concentration factors, depending on the chosen pre-treatment. Additionally, an economic analysis of the operational cost, taking as case study a site where the current management of the brine is the discharge to the sea, was also carried out. Results showed that pre-treatments enhanced MD performance by increasing the concentration factor achieved and highest volume reductions (about 3 times) were reached with the combination of acidification and aeration pre-treatments. Both processes reduced the precipitation potential of CaCO₃(s) by reducing the total inorganic carbon (>90%); however, CaSO₄·2H₂O(s) precipitated. Results also indicated that even if a waste heat source is available, brine disposal into the sea is the cheapest option, while ZLD alternatives were not attractive in the current regulatory framework since their cost was higher than the discharge to the sea. Other options related to the Minimal Liquid Discharge may be more economically attractive.

Valorisation options for Zn and Cu recovery from metal influenced acid mine waters through selective precipitation and ion-exchange processes: promotion of on-site/off-site management options

Acid mine waters (AMWs), generated in the processing of polymetallic sulphides, contain copper and zinc as the main valuable transition metal ions, which are typically removed by liming, due to their great environmental impact. In this context, this work proposes the integration of selective precipitation (SP) and ion-exchange (IX) processes for the separation and recovery of both valuable metals to encourage on-site and off-site management options promoting valorisation routes. Thus, the main objectives of this work were (i) the selective removal of Fe(III) and Al(III), using NaOH under pH control (pH < 5) to avoid the precipitation of Cu(II) and Zn(II) and (ii) the evaluation of a solvent-impregnated resin (Lewatit VP OC 1026, named VP1026) and a cation IX resin (Lewatit TP 207, named TP207) for the sequential extraction of both metal ions from AMW (batch and column experiments). Results indicated that the metallic pollution load was mostly removed during the SP process of Fe(III) (>99%) and Al(III) (>90%) as hydroxylsulphates (e.g., schwertmannite and basaluminite). The metal extraction profiles were determined for both metals from pH 1 to pH 5 by batch experiments, and indicated that the best extraction of Zn(II) was obtained using VP1026, being higher than 96% (pH = 2.6-2.8), whereas TP207 extraction performance was optimal for Cu(II) extraction (>99%) at pH = 3-4. Moreover, in dynamic experiments using a fixed-bed configuration, it was possible to separate and concentrate Zn(II) (concentration factor = 10) and Cu(II) (concentration factor = 40) using VP1026 and TP207, respectively. Overall, the integration of SP and IX processes showed a great potential in the separation and recovery of valuable metals from mine waters to promote a circular economy, based on the management proposal for non-ferrous metallurgical industries. The recovered Zn-rich and Cu-rich sulphuric concentrated streams were theoretically evaluated for further on-site or off-site re-use treatments (e.g., electrowinning, precipitation, crystallization).

Arsenic impact on the valorisation schemes of acidic mine waters of the Iberian Pyrite Belt: Integration of selective precipitation and spiral-wound nanofiltration processes

Arsenic and selenium presence in acid mine waters (AMWs) limits their disposal due to environmental regulations. The focus to solve the economic infeasibility is directed to sustainable solutions, promoting resource recovery. In fact, rare earth elements (REEs) recovery is proposed in most of the Iberian Pyrite Belt AMWs. However, the presence of arsenic and selenium may impact in the REEs recovery. Among different alternatives, nanofiltration (NF) provides a concentration stage on REEs recovery, reduces the nominal flow and removes hazardous species. In this work, Iberian Pyrite Belt AMWs with up to 10 mg/L REEs, containing arsenic (2 mg/L), were treated with a NF membrane. Firstly, AMWs were pre-treated with H₂O₂/NaOH, to oxidise Fe(II) to Fe(II) and As(III) to As(V), promoting their removal and avoiding their potential precipitation at the membrane. Subsequently, NF pressure effect (6-20 bar) was studied, removing metals (>95 %), whereas arsenic rejections ranged from 60 to 71 %. Then, water recovery potential was evaluated at 10, 15 and 22 bar by reproducing a 10-stages NF plant. Results showed that the proposed treatment could be an alternative for arsenic and selenium removal (70 μg/L and 0.5 μg/L permeate concentrations, respectively) to achieve mining discharge limits according to regulations.

Analysis of two-phase air-water annular flow in U-bends

This paper presents an experimental and numerical study of gas-liquid annular flow in horizontal 180 U-bends. The paper aims to study the effect of bend curvature radius and superficial gas velocity in the liquid film's behavior and annular flow characteristics. The study is divided into three sections. The first section corresponds to the experimental methodology and results. The second section compresses the validation of the computational fluid dynamic (CFD) model with the experimental results. Finally, the last section presents the CFD estimation of additional variables that cannot be acquired with the existing experimental setup. The experimental results provide an initial understanding of the multiphase mixture obtained using optical techniques (i.e., High-Speed Filming (HSF) analysis). The comparison between the experiments and the numerical simulations is presented, and a reasonable agreement is observed between both approaches. Finally, additional results such as film distribution and rotation before and after the bend are extracted from the CFD simulations.

Changes in hemodynamics, renal blood flow and urine output during continuous renal replacement therapies

Continuous renal replacement therapies (CRRT) affect hemodynamics and urine output. Some theories suggest a reduced renal blood flow as the cause of the decreased urine output, but the exact mechanisms remain unclear. A prospective experimental study was carried out in 32 piglets (2–3 months old) in order to compare the impact of CRRT on hemodynamics, renal perfusion, urine output and renal function in healthy animals and in those with non-oliguric acute kidney injury (AKI). CRRT was started according to our clinical protocol, with an initial blood flow of 20 ml/min, with 10 ml/min increases every minute until a goal flow of 5 ml/kg/min. Heart rate, blood pressure, central venous pressure, cardiac output, renal blood flow and urine output were registered at baseline and during the first 6 h of CRRT. Blood and urine samples were drawn at baseline and after 2 and 6 h of therapy. Blood pressure, cardiac index and urine output significantly decreased after starting CRRT in all piglets. Renal blood flow, however, steadily increased throughout the study. Cisplatin piglets had lower cardiac index, higher vascular resistance, lower renal blood flow and lower urine output than control piglets. Plasma levels of ADH and urine levels of aquaporin-2 were lower, whereas kidney injury biomarkers were higher in the cisplatin group of piglets. According to our findings, a reduced renal blood flow doesn’t seem to be the cause of the decrease in urine output after starting CRRT.

From nanofiltration membrane permeances to design projections for the remediation and valorisation of acid mine waters

Acidic Mine Waters (AMWs) are characterised by high acidity (pH < 3) as H₂SO₄ and elevated contents of metals (Al, Fe, Cu, Zn), including rare earth elements (REEs). Due to the exhaustion of minable REE containing-minerals, AMWs are increasingly regarded as an alternative source of REEs. Among the different alternatives for the pre-concentration of AMWs required to make the REE extraction possible, nanofiltration (NF) membranes emerge as a promising technology because they not only successfully reject multivalent ions (metals), allowing its concentration in the retentate stream, but also permit the transport of monovalent ones, such as H⁺ and HSO₄^-, allowing the recovery of sulphuric acid in the permeate. Despite this potential of NF, there is still a lack of modelling tools for predicting the performance of NF membranes because of its dependence on solution composition, membrane properties and interaction between both. In this study, a prediction tool based on the Solution-Electro-Diffusion model (including the effect of solution composition) was developed and experimentally validated for the application of two polyamide-based NF membranes (NF270 and Desal DL) for the recovery of REEs and H₂SO₄ from three different synthetic solutions mimicking AMWs (pH 1.0, 60 mg/L REEs and, 25-600 mg/L Al, Cu, Ca and Zn) differing in their Fe concentration (0-2125 mg/L). Metals were effectively rejected (>98%), whereas H₂SO₄ was transported across the membrane (H+ rejections <30%). The mathematical model was able to predict the performance of both membranes as well as the potential scaling events associated with Fe and Al hydroxides and hydroxy-sulphates.

Effectiveness of interventions related to continuity of health care in five Latin America countries

Background

Evaluation of interventions to improve continuity of care across care levels is scarce in Latin America. The

Aim

to analyse the impact of implemented interventions on the perception of continuity of care of chronic patients in public health care networks of five LA countries (Brazil, Chile, Colombia, Mexico, and Uruguay).

Methods

Quasi-experimental study (controlled before and after design). Comparable networks, one intervention (IN) and one control (CN) were selected in each country. Baseline (2015) and evaluation (2017) surveys were conducted applying CCAENA questionnaire® to a sample of patients with chronic conditions (392/network; 784/country/year). Result variables: information continuity (exchange of clinical information) and clinical management continuity (repetition of exams, accessibility of primary care (PC) and secondary care (SC), perception of agreement between PC and SC doctors and of collaboration between PC and SC doctors. Descriptive analysis were conducted, and chi-square test was calculated to determine significant changes.

Results

An increase in the perception of continuity of information between care levels was observed in the IN of all countries, but Colombia. Clinical management continuity: decrease in the repetition of exams and increase in accessibility of consultation with the specialist in all countries but Mexico. The accessibility of PC doctor decreased in the IN in all countries. No differences in the perception of agreement between PC and SC doctors regarding diagnosis, treatment and recommendations were found. The perception of collaboration between PC and SC doctors increased in the five countries.

Conclusions

Consistent with expected results, the level of perceived information continuity and clinical management continuity increased in the IN, with differences between countries. Further multivariate analyses will be conducted to explore the differences between the IN and CN.

Key messages

Provides a cross-country comparison of the perception of continuity of care in patients with chronic conditions. Contributes to fill the knowledge gap on the effectiveness of participatory interventions improving continuity of care.

Outcomes and conditions for sustaining changes of Participatory Action Research interventions

Background

Finding new strategies for care integration has become a priority for many health systems in Latin America. Although the implementation of interventions through a participatory action research (PAR) approach is considered effective, its application in health services is scarce.

Aim

to analyse impact of PAR interventions on care coordination, and aspects for sustainability and transferability in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay.

Methods

A qualitative, descriptive-interpretative study was conducted in each healthcare network. Focus groups and individual semi-structured interviews were conducted to a criteria sample of Local Steering Committee (29), Platform of professionals (28), professionals (49) y managers (28). A thematic content analysis was conducted, segmented by country and themes. Different interventions were designed and implemented through a PAR process: joint meetings to discuss clinical cases and/or training; shared care guidelines; offline virtual consultations; a (back) referral form; and an induction program.

Results

Informants highlighted that joint meetings based on reflexive methods contributed substantially to improving contextually relevant elements of clinical coordination - communication in patient follow-up, clinical agreement, appropriateness of referrals - and administrative coordination. The meetings, alongside the PAR process, helped to improve interaction between professionals, fostering willingness to collaborate. No significant contributions were identified in the remaining interventions due to the low uptake. A necessary condition for the sustainability and replicability of the interventions was that the PAR process had to be used appropriately in a favorable context.

Conclusions

Evidence is provided on the significant contribution of interventions to improving locally relevant clinical coordination elements and professional interaction when implemented through an adequate PAR process.

Key messages

It contributes to fill the gap regarding the impact of PAR interventions on care coordination. A key aspect for impact and sustainability is an adequate use of PAR approach in a favourable context.

Endothelial dysfunction is an early indicator of sepsis and neutrophil degranulation of septic shock in surgical patients

Background

Stratification of the severity of infection is currently based on the Sequential Organ Failure Assessment (SOFA) score, which is difficult to calculate outside the ICU. Biomarkers could help to stratify the severity of infection in surgical patients.

Methods

Levels of ten biomarkers indicating endothelial dysfunction, 22 indicating emergency granulopoiesis, and six denoting neutrophil degranulation were compared in three groups of patients in the first 12 h after diagnosis at three Spanish hospitals.

Results

There were 100 patients with infection, 95 with sepsis and 57 with septic shock. Seven biomarkers indicating endothelial dysfunction (mid‐regional proadrenomedullin (MR‐ProADM), syndecan 1, thrombomodulin, angiopoietin 2, endothelial cell‐specific molecule 1, vascular cell adhesion molecule 1 and E‐selectin) had stronger associations with sepsis than infection alone. MR‐ProADM had the highest odds ratio (OR) in multivariable analysis (OR 11·53, 95 per cent c.i. 4·15 to 32·08; P = 0·006) and the best area under the curve (AUC) for detecting sepsis (0·86, 95 per cent c.i. 0·80 to 0·91; P < 0·001). In a comparison of sepsis with septic shock, two biomarkers of neutrophil degranulation, proteinase 3 (OR 8·09, 1·34 to 48·91; P = 0·028) and lipocalin 2 (OR 6·62, 2·47 to 17·77; P = 0·002), had the strongest association with septic shock, but lipocalin 2 exhibited the highest AUC (0·81, 0·73 to 0·90; P < 0·001).

Conclusion

MR‐ProADM and lipocalin 2 could be alternatives to the SOFA score in the detection of sepsis and septic shock respectively in surgical patients with infection.

Incorporating posttransplant cyclophosphamide-based prophylaxis as standard-of-care outside the haploidentical setting: challenges and review of the literature

Posttransplant high-dose cyclophosphamide (PTCy) effectively prevents GvHD after haploidentical SCT. However, its use in HLA-matched SCT has been less explored. Fifty-six consecutive patients who underwent allo-SCT for hematological malignancies have been included in this prospective single-center protocol. Donors have been HLA-identical siblings, fully-matched unrelated or 1-allele-mismatched unrelated donors in 30%, 32%, and 37% of cases, respectively. Nine patients have received a TBI-containing MAC regimen, while the remaining (84%) received RIC platforms based on Fludarabine plus Busulfan/Melphalan. Due to the high graft failure (GF) rate (21%) in a preliminary analysis in the allo-RIC cohort (n = 29), protocol amendments have been implemented, with no further cases of GF after the introduction of mini-thiotepa (0/18). The overall incidence of grade II-IV acute GvHD is 24% (95% CI: 17-31%) with four steroid-refractory cases. Severe chronic GvHD has occurred in only 1 of 43 evaluable cases. The 1-year NRM and relapse are 18% (95% CI: 12-26%) and 30% (18-42%) and the OS and DFS are 78% and 64%, respectively. These outcomes support the feasibility of using PTCy as a SOC outside the haplo-setting, albeit mini-thiotepa (3 mg/kg) was incorporated in the standard allo-RIC platforms to prevent GF. Despite the limitations of a single-center experience and the short follow-up, these protocols show promising results with particular benefit in reducing the occurrence of moderate-to-severe GvHD.

[Posttraumatic growth in parents of children and adolescents with cancer]

Cancer can provoke negative psychological reactions. Nevertheless, coping with oncological issues can also result in positive psychological changes that demonstrate the strength of the human being, one of them being posttraumatic growth (PTG). The aim of this narrative review was to examine and analyze studies, published from 2000 to 2018 and available in different data sets, that focus on PTG in parents of children and adolescents with cancer in the pediatric context. Twenty studies were identified, including 2,422 subjects, mainly mothers (n=1,788). PTG was analyzed according to the differences among relatives, outcome and type of oncological disease, and its predictor factors. Fathers and mothers are both capable of developing PTG as a result of their children's disease, mothers being the ones who present higher levels. Compared with other samples like parents of children with type I diabetes or healthy children, or adult patients with osteosarcoma, parents of children with cancer present more PTG. Likewise, factors that influence the development of PTG, such as cultural context, cognitive processing, adjustment to the disease and certain personality traits are observed. The published clinical evidence endorses the existence of PTG in parents of children with cancer. However, it would be necessary to carry out further investigation, particularly subjective and longitudinal studies with larger homogeneous samples, in order to design interventions aimed at promoting PTG and avoid focusing solely on the negative aspects of oncological disease in children.

Can clinical coordination be improved through Participatory Action Research (PAR) interventions?

Background

Despite the effectiveness of Participatory Action Research (PAR) in reducing the gap between evidence and practice, its use to improve care integration is rare. The aim is to analyze the factors influencing the implementation of PAR interventions to improve clinical coordination in public health services networks of Brazil, Chile, Colombia, Mexico and Uruguay.

Methods

A qualitative, descriptive-interpretative study was conducted in participating healthcare networks of each country. Focus groups and individual semi-structured interviews were conducted to a criteria sample of participants: members of Local Steering Committee (LSC)(29), professionals’ platform (PP)(28), other professionals (49) and managers(28). Thematic content analysis was performed, segmented by country and themes.

Results

Findings reveal that contextual factors, the PAR process and interventions’ content were determinants in the implementation, interacting over time, and differing among experiences. On the one hand, institutional support (providing the necessary resources) together with the interest of professionals and managers in participating, emerged as influencing factors influenced by other factors related to: the system (alignment with policies; electoral cycle), networks (lack of time due to work overload; precarious employment conditions) and individuals (limited mutual knowledge and mistrust). On the other, some characteristics of the PAR process facilitated institutional support and motivation: professionals’ participation in all activities, design flexibility and shared decision-making - also present when interventions were based on mutual adjustment - the LSC’s leadership and the facilitating role of the research team.

Conclusions

Evidence is provided that when some contextual elements converge the implementation of interventions through PAR processes can turn into a factor of motivation and cohesion, determinant for the adoption of clinical coordination interventions.

Key messages

Contributes to fill the knowledge gap in factors influencing the implementation of PAR interventions in healthcare. Provides a framework for analysis and recommendations for their implementation.

Effectiveness of participatory interventions in improving clinical coordination in Latin America

Background

Evaluation of interventions to improve clinical coordination across care levels is scarce in Latin America.

Aim

to evaluate the effectiveness of interventions implemented through participatory action research in improving clinical coordination between care levels in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay.

Methods

Quasi-experimental study (controlled before and after design). Comparable networks, one intervention (IN) and one control (CN), were selected in each country. Baseline (2015) and evaluation (2017) surveys were conducted applying COORDENA® questionnaire to a sample of primary (PC) and secondary (SC) care doctors (174 doctors/network/year). Designed interventions promoted clinical agreement and communication across levels for patients’ follow-up. Outcome variables: a) intermediate: interactional and organizational factors; b) final: experience of clinical management coordination (care consistency and patients’ follow-up) and general perception of coordination between levels. Poisson regression models were estimated.

Results

Intermediate: interactional factors -personal knowledge and trust on the other care level-increased significantly in Brazil’ and Chile’ INs; and organizational factors -managers’ support- in the INs of Colombia and Mexico. Comparing to CN in 2017, INs of Brazil, Chile, Colombia and Mexico showed significant differences in some factors.

Final: care consistency items -agreement over the treatments- improved in the INs of Brazil, Colombia and Uruguay; and patients’ follow-up in the INs of Chile and Mexico. General perception of clinical coordination increased in the INs of Brazil, Colombia and Mexico. Compared to CN in 2017, only Brazil showed significant differences.

Conclusions

Improvements in intermediate and final care coordination results, consistent with expected results, were observed in all the INs. Reduced implementation time and some process and context factors may have limited their impact.

Key messages

First study assessing the effectiveness of participatory interventions in improving clinical coordination between care levels in public healthcare networks of Latin America. Results showed changes in the intermediate and final clinical coordination results in the intervention networks. Longer implementation and evaluation times are expected to achieve greater impact.

Third-order nonlinear optical properties of a multi-layer Al2O3/ZnO for nonlinear optical waveguides

This is a report of a study of the nonlinear optical properties of samples based on multiple Al₂O₃/ZnO bilayers fabricated by atomic layer deposition (ALD) in silica. The multi-layer configuration for samples consists of alternated layers of constant thickness of Al₂O₃ (Δx) and ZnO (Δy) nanolaminates with a total thickness of ∼ 500 nm. The physical properties of the samples were characterized by means of TEM, spectrophotometry and variable angle spectroscopic ellipsometry. The absorptive and refractive contributions to the nonlinearity of the samples were studied by means of z-scan technique using a 100 fs at 800 nm. The nonlinear parameters, β and n₂, are studied using different values of the layers thickness, Δx and Δy, in the nanolaminated stack. The possible applications in optical signal processing system are discussed by means of the figures of merit W and T.

Aerosolized Lipid Amphotericin B for Complementary Therapy and/or Secondary Prophylaxis in Patients with Invasive Pulmonary Aspergillosis: A Single-Center Experience

BACKGROUND

Experience with aerosolized lipid amphotericin B (aeLAB) as therapy or secondary prophylaxis in patients with invasive pulmonary aspergillosis (IPA) is anecdotal.

METHODS

We performed a single-center retrospective cohort study to evaluate the efficacy of systemic antifungal therapy with and without aeLAB in patients with proven or probable IPA. Complete or partial response at 3 months was the primary end-point. Clinical response and mortality at 12 months, occurrence of adverse drug reactions and respiratory fungal colonization were secondary end-point.

RESULTS

Eleven patients (39%) received aeLAB in addition to systemic antifungal therapy (group A), and 22 (61%) received systemic antifungal therapy only (group B). The use of aeLAB was not standardized. Amphotericin B lipid complex was used in all patients but one, who received liposomal amphotericin B. Five patients received aeLAB as antifungal complementary therapy and 6 received it as secondary prophylaxis. Except for the requirement of inhaled corticosteroids and home oxygen therapy, more frequent in group A, both groups were similar in baseline conditions. A better (nonsignificant) clinical outcome was observed at 3 months in patients receiving aeLAB. Only uncontrolled baseline condition was associated with one-year mortality in univariate analysis (p = 0.002). A multivariate Cox regression analysis suggests that aeLAB, corrected for uncontrolled underlying disease, reduces mortality at 12 months (HR 0.258; 95% CI 0.072-0.922; p = 0.037).

CONCLUSION

Although no significant difference was observed in the main variable (3-month clinical response) and in spite of methodological limitations of the study, the possible survival benefit of aeLAB, adjusted for the control of the underlying disease, could justify the performance of well-controlled studies with a greater number of patients.

Scar sarcoidosis: A rare entity found by 18F-FDG-PET/CT

¹⁸F-labeled fluoro-2-positron deoxyglucose emission tomography/computed tomography has been widely used in malignancy assessment, however, is not tumor-specific and may be taken up by non-malignant conditions such as sarcoidosis. Sarcoidosis is a systemic inflammatory disorder and scar sarcoidosis is a rare manifestation of the disease. A 60-year-old man with a past medical history of synchronous colon adenocarcinoma and clear cell renal cell carcinoma with clinical suspicion of tumor recurrence. ¹⁸F-labeled fluoro-2-positron deoxyglucose emission tomography/computed tomography scan demonstrated lesions with increased fluorodeoxyglucose uptake in mediastinal and left supraclavicular lymph nodes, along with hypermetabolic cutaneous foci that corresponded with previous surgical scars. Skin biopsy was suggestive of sarcoidosis.

Synthesis of Copper Nanowires and Their Antimicrobial Activity on Strains Isolated Persistent Endodontic Infections

Copper nanowires, Cu-NWs may have a good antimicrobial effect in endodontic treatment. The objective of this work was to synthesize, characterize and evaluate the antibacterial activity of Cu-NWs on strains obtained from human root canal. A wide distribution of Cu-NWs diameters from 30 to 90 nm was obtained with lengths ranging from 5 to 40 μm. Structural analysis of Cu-NWs showed crystalline planes, which corresponded to Cu, with preferential growth in the direction [110]. The geometric mean MICs was of 289.30 μg/mL, with a MIC50 of 256 μg/mL and a MIC90 of 512 μg/mL for Cu-NWs. Cellular viability of 28 a biofilm tends to decrease the longer it is exposed to Cu-NWs. Synthesized and characterized Cu-NWs have a good antimicrobial effect against clinical strains used in the present study and has a potential to be used for disinfection of the root canal system.

[Multidisciplinary approach on subglottic pathology: a 5-year review]

INTRODUCTION

Pediatric subglottic pathology still represents a challenge when it comes to choosing the right treatment. We present the management of patients followed in our center for this reason during the last 5 years.

MATERIAL AND METHODS

Retrospective study of patients followed by glotosubglottic pathology (stenosis, cysts or granulomas) between 2011 and 2016 in a third level hospital.

RESULTS

Twenty-seven patients were included in the review. Treatment options varied according to the nature, location and severity of the subglottic stenosis. Two patients with congenital subglottic stenosis were treated by laryngotracheoplasty. Seventeen patients with acquired subglottic stenosis were included: in one (5.9%) laryngotracheoplasty was performed, one (5.9%) received cricotracheal split, two of them (11.8%) underwent partial cricotracheal resection (PCTR) , seven patients (41.2%) underwent microsurgery, three (17.6%) received tracheal dilatation, and the last three (17.6%) were submitted to observation without needing further treatment. Five patients with post-intubation subglottic cysts received microsurgery. Of three patients diagnosed with post-intubation subglottic granuloma, two (66%) resolved spontaneously and one (33%) required microsurgery.

CONCLUSIONS

Management of pediatric subglottic pathology remains a major challenge. Since the creation of the Airway Committee in our center, the improvement in the management of these patients has led to a multidisciplinary management, with the consequent impact on the clinical results.

[Decolonization for Staphylococcus aureus carriers in arthroplasty surgery after hip fracture]

OBJECTIVE

Staphylococcus aureus is the main causative agent of joint prosthesis infections. The decolonization of the carriers is effective in the prevention of the infections of the elective arthroplasties. The aim of this study is to evaluate if it is also in arthroplasties after hip fracture.

METHODS

Study in patients with hip fracture who underwent joint prosthesis from January 2011 to December 2015 with a protocol of S. aureus detection-decolonization with intranasal mupirocin and chlorhexidine baths. Patients between January 2009 and December 2010 were the comparison group.

RESULTS

In the intervention period, the study of colonization of S. aureus was performed in 307 patients, of whom 87 were positive (28.3%). The study period was completed by 267 patients, of whom two developed S. aureus infection, compared to six of 138 in the control group (0.7% vs 4.3%, RR 0.1, p = 0.03).

CONCLUSIONS

In our study, S. aureus decolonization in patients with hip fracture decreased the incidence of joint prosthesis infection by this microorganism.

Confirmed mixed bird-insect pollination system of Scrophularia trifoliata L., a Tyrrhenian species with corolla spots

Both bird and mixed vertebrate-insect (MVI) pollination systems are very rare in Europe and the Mediterranean region. Because MVI can ensure reproduction over a wider range of environmental conditions than when insects are the sole pollinators, under certain circumstances such systems are highly advantageous to plants. Here, we investigated the pollination and some reproductive traits of the Tyrrhenian Scrophularia trifoliata, the only species of the genus possessing two showy dark spots inside the corolla, for which MVI pollination system had been inferred on the basis of limited censuses. We conducted field experiments to study MVI pollination and some reproductive traits and elucidate the role of corolla spots, analysing their ultraviolet pattern, histology and pigments versus the rest of the corolla. The primary pollinators were wasps and passerine birds. Corolla spots absorb UV light, present abundant anthocyanins and are histologically identical to the rest of the corolla. Control flowers had higher visitation frequency than flowers without spots. S. trifoliata is self-compatible, with efficient intrafloral protogyny and herkogamy that prevent self-pollination but not geitonogamy. We confirmed the existence of a mixed bird-insect pollination system in S. trifoliata. This system is found in three other Scrophularia species with large, showy flowers - two Mediterranean (S. grandiflora and S. sambucifolia) and one Macaronesian (S. calliantha). Unlike those species, S. trifoliata has two large spots inside the corolla. These likely operate as nectar guides and their dark colouration is related to abundant anthocyanin content.

International experts' practice in the antibiotic therapy of infective endocarditis is not following the guidelines

OBJECTIVE

The management of infective endocarditis (IE) may differ from international guidelines, even in reference centres. This is probably because most recommendations are not based on hard evidence, so the consensus obtained for the guidelines does not represent actual practices. For this reason, we aimed to evaluate this question in the particular field of antibiotic therapy.

METHODS

Thirteen international centres specialized in the management of IE were selected, according to their reputation, clinical results, original research publications and quotations. They were asked to detail their actual practice in terms of IE antibiotic treatment in various bacteriological and clinical situations. They were also asked to declare their IE-related in-hospital mortality for the year 2015.

RESULTS

The global compliance with guidelines concerning antibiotic therapy was 58%, revealing the differences between theoretical 'consensus', local recommendations and actual practice. Some conflicts of interest were also probably expressed. The adherence to guidelines was 100% when the protocol was simple, and decreased with the seriousness of the situation (Staphylococus spp. 54%-62%) or in blood-culture-negative endocarditis (0%-15%) that requires adaptation to clinical and epidemiological data.

CONCLUSION

Worldwide experts in IE management, although the majority of them were involved and co-signed the guidelines, do not follow international consensus guidelines on the particular point of the use of antibiotics.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Design and properties of 3D scaffolds for bone tissue engineering

In this study, the Voronoi tessellation method has been used to design novel bone like three dimension (3D) porous scaffolds. The Voronoi method has been processed with computer design software to obtain 3D virtual isotropic porous interconnected models, exactly matching the main histomorphometric indices of trabecular bone (trabecular thickness, trabecular separation, trabecular number, bone volume to total volume ratio, bone surface to bone volume ratio, etc.). These bone like models have been further computed for mechanical (elastic modulus) and fluid mass transport (permeability) properties. The results show that the final properties of the scaffolds can be controlled during their microstructure and histomorphometric initial design stage. It is also shown that final properties can be tuned during the design stage to exactly match those of trabecular natural bone. Moreover, identical total porosity models can be designed with quite different specific bone surface area and thus, this specific microstructural feature can be used to favour cell adhesion, migration and, ultimately, new bone apposition (i.e. osteoconduction). Once the virtual models are fully characterized and optimized, these can be easily 3D printed by additive manufacturing and/or stereolitography technologies.

STATEMENT OF SIGNIFICANCE

The significance of this article goes far beyond the specific objectives on which it is focussed. In fact, it shows, in a guided way, the entire novel process that can be followed to design graded porous implants, whatever its external shape and geometry, but internally tuned to the exact histomorphometric indices needed to match natural human tissues microstructures and, consequently, their mechanical and fluid properties, among others. The significance is even more relevant nowadays thanks to the available new computing and design software that is easily linked to the 3D printing new technologies. It is this transversality, at the frontier of different disciplines, the main characteristic that gives this article a high scientific impact and interest to a broaden audience.